File No. STATE OF NORTH CAROLINA In The General Court Of Justice County District Court Division IN THE MATTER OF Name Of Juvenile JUVENILE SUMMONS AND NOTICE OF HEARING (OBSTRUCTION OF OR INTERFERENCE WITH JUVENILE INVESTIGATION) G.S. 7B-303 To Each Of The Person(s) Named Below: Name And Address Of Respondent 1 Name And Address Of Respondent 2 Parent Other (specify) Parent Other (specify) Name And Address Of Other Person To Be Served Name And Address Of Other Person To Be Served Parent Other (specify) Parent Other (specify) A petition has been filed alleging that the respondent(s) named above is/are obstructing and/or interfering with an investigation of a report that the juvenile named above is abused, neglected, or dependent, or has died as a result of suspected maltreatment. SUMMONS AND NOTICE OF HEARING ON PETITION You are SUMMONED to appear on the date and at the time and location set forth below: for a hearing to determine whether the attached ex parte order should be continued or a different order entered. for a hearing on the attached petition. Date Of Hearing Time Of Hearing Location Of Hearing AM PM Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court AOC-J-121, New 7/99 1999 Administrative Office of the Courts (Over) >>>> 2 RETURN OF SERVICE I certify that this Summons and a copy of the petition were received and served as follows: RESPONDENT 1Date Served Name Of Person To Be Served By delivering to the person named above a copy of the summons and petition. By leaving a copy of the summons and petition at the dwelling house or usual place of abode of the person named above with a person of suitable age and discretion then residing therein.Name And Address Of Person With Whom Copies Left This person WAS NOT served for the following reason: RESPONDENT 2Date Served Name Of Person To Be Served By delivering to the person named above a copy of the summons and petition. By leaving a copy of the summons and petition at the dwelling house or usual place of abode of the person named above with a person of suitable age and discretion then residing therein.Name And Address Of Person With Whom Copies Left This person WAS NOT served for the following reason: OTHER PERSON TO BE SERVED 1Date Served Name Of Person To Be Served By delivering to the person named above a copy of the summons and petition. By leaving a copy of the summons and petition at the dwelling house or usual place of abode of the person named above with a person of suitable age and discretion then residing therein.Name And Address Of Person With Whom Copies Left This person WAS NOT served for the following reason: OTHER PERSON TO BE SERVED 2Date Served Name Of Person To Be Served By delivering to the person named above a copy of the summons and petition. By leaving a copy of the summons and petition at the dwelling house or usual place of abode of the person named above with a person of suitable age and discretion then residing therein.Name And Address Of Person With Whom Copies Left This person WAS NOT served for the following reason: Date Received Date Of Return Name Of SheriffCounty Deputy Sheriff Making Return AOC-J-121, Side Two, New 7/99 1999 Administrative Office of the Courts